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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN <br /> ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME,ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS LETTER. <br /> PROJECT CONTACT: CONTACT PHONE# <br /> r-/—MELA CVL&,�-RT-Sony ch G-spc-)-1? - <br /> FACILITY NAME:-ltd j0A QV)N R-T-p FACILITY PHONE# <br /> REa u <br /> FACILITY ADDRESS: CROSS STREET: <br /> 2. 34 q F- K>IRT'L E S� gs�os <br /> OWNER/OPERATOR: PHONE: <br /> SAN. TOA Q v t Int >= 1?7D 2 p c'---.z}O,9—LJ4 S <br /> CONTRACTOR NAME: PHONE: <br /> Pf—�7-,F=7tZ ScgN jYXDj?BL)LjC-S I9c- <br /> CONTRACTOR ADDRESS: ) GS-:5 W, � 5EGVfjA>CA LICENSE# <br /> 131-AX? o>= I\LA j cR 9 0 q 4 <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> YES 1✓ NO <br /> FIRE DISTRICT: PERMIT# <br /> BOARD OF EQUALIZATION# <br /> sRAB `17, 4q S <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> O v S o L_ <br /> C> S L_ &, <br /> �i <br /> ❑APPROVED ❑APPROVED WITH CONDITIONS ❑DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER'S NAME DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, <br /> RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S <br /> SIGNATURE CERTIFIES THE FOLLOWING" I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br /> PERMIT IS ISSUED., I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE <br /> CERTIFIES THE FOLLOWING "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS <br /> ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> Applicant's Signature � Q.s?/t 3 ,• <br /> Title C 0 hLTjZ A GT 0 2 Date 4—L C�•-1 <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8-hour minimum installation <br /> payment.The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name F�E'7�l2Sb�I b}Y DRQ I L,J ��4 1 NC'. Date.4— 9' -- f Z{ <br /> Mailing Address S JI/D D <br /> Signature Daytime Phone `�f �-.�� 3 --3155' <br /> Revised 07/24/13 3 <br />